Health system performance assessment and reforms, Oman

Abstract Problem To prioritize key areas of action and investment for the next strategic cycle of national development plans (2026–2031) in Oman, we needed a holistic view of the country’s health system and its main deficiencies and inefficiencies. Approach Informed by the World Health Organization framework, our team of seven national health ministry staff and two international experts conducted a rapid health system performance assessment. We used already available data to identify system bottlenecks and their potential root causes, verifying our findings with key informant interviews. Local setting Oman’s 4.9 million population is relatively young (average age 28 years) but ageing, with a mounting burden of chronic diseases. While health-care services are free for Omani nationals, more than 1.5 million expatriates rely on out-of-pocket payments for health-care services. Strengthening primary health care, improving the quality of care, providing financial protection, and ensuring that public and private health-care providers operate within the same legal and procedural framework are recognized as key national priorities. Relevant changes Our assessment highlighted the need to extend health service coverage to the whole population, strengthen private health-care sector governance, improve health education, increase financial investment, and expand the country’s capacity for data collection and analysis. Lessons learnt The assessment framework allowed us to identify areas where information is lacking and use already available data to analyse multiple health outcomes. As well as identifying issues that need to be addressed during the next policy development cycle, our findings have contributed towards the preparation of a more extensive assessment.


Introduction
Health systems are constantly changing; regular wide-ranging assessments of their performance help to identify and adjust priorities, 1,2 and inform actions for their robust and resilient transformation.Originally developed by the World Health Organization (WHO) 3 for this purpose, the health system performance assessment framework becomes an effective tool when combined with policy-cycle and strategic health system development plans. 3s part of Oman Vision 2040, the health ministry formulates the design and aims of the country's health system and submits these for consideration to the Oman 2040 Committee for inclusion in the successive 5-year national development plans. 4The Cabinet of Ministers of Oman initiated the development of the next 5-year cycle for the period 2026-2031 in January 2023 by requesting its health ministry to report on the performance of Oman's health system by April 2023.This performance report enabled the identification of health system investment needs and guided preliminary discussion to develop goals and priorities for 2026-2031.
Here we report on the application and use of the health system performance assessment tool for the first time in Oman, with the specific aim of informing and focusing the planning of reforms in the health sector.

Local setting
The population of Oman was 4.9 million in 2023. 5,66][7] Population growth is slowing 6,8 and the burden of noncommunicable diseases (e.g.diabetes) is increasing. 7mani nationals have access to health care from publicly owned health-care service providers.More than 1.5 million expatriates rely on out-of-pocket payments for their healthcare needs.Continuous strengthening of primary health care (e.g. by increasing the number of health-care facilities and appropriately trained and funded staff); improving the quality of health care (e.g.developing and updating treatment guidelines); providing financial protection; and ensuring that public and private health-care service providers operate within the same legal and procedural framework are recognized as key national priorities. 9

Approach
We chose the health system performance assessment framework published by WHO in 2022 10 to guide an assessment of the performance of the Omani health system.This WHO framework helps us to review health system functions and subfunctions, understand their interactions, and evaluate their impact on health system intermediate and final outcomesincluding the collection and analysis of necessary data -in a systematic manner.Considering the deadline, the health ministry formed a small team to conduct a rapid health system performance assessment using only already available data.
Members of the national assessment team included seven health ministry staff members qualified in a range of individual health system (sub)functions -namely governance, financing, human resources, specialized and primary care Taavi Lai et al.
Lessons from the field service delivery, and pharmaceuticals -and in the integration of these (sub) functions into a national health system.We compiled data describing these individual health system (sub)functions and on intermediate and final outcomes from readily available national 5 and international databases. 7,11,12The national assessment team was then joined by two international experts with experience in both the development and application of health system performance assessment frameworks.Our extended team (national and international members) collaborated in the integration of preliminary findings, the identification of data gaps and the collection of such additional data (especially on health system outcomes), the clarification of main findings and the identification of priority areas of action.
We conducted a stepwise analysis to assess the performance of the health system.Beginning with available data to obtain an overview of results across indicators, we conducted consecutive rounds of analysis where the health outcome findings (e.g.low life expectancy) are verified or their potential factors (e.g.low vaccine coverage, high obesity prevalence or poor accessibility of primary health care) are investigated further with additional data (combinations) or analytical approaches.Such an approach helps to identify the root causes (i.e.healthcare practices that can be introduced, extended or improved) of health system bottlenecks (i.e.deficiencies, inefficiencies, restrictions and delays), essential for achieving universal health coverage and improved health security.We then verified our initial identification of such root causes by interviewing key informants, such as health ministry advisors.We conducted 10 such interviews during the assessment process, predominantly with health ministry staff members who were not involved in the assessment process.
The cost of conducting the rapid health system performance assessment was around 40 000 United States dollars, including material, lodging and the time of national and international expertise.Our health system performance assessment culminated with the presentation of our report 9 to the health ministry leadership and participation in discussions of our findings.The health ministry then submitted our report, with recommendations for policy action, to the Cabinet of Ministers.

Relevant changes
Our rapid health system performance assessment identified several changes that should be incorporated within the health system goals and priorities for the next 5-year development plan; several areas of health-care provision and governance should be strengthened, and additional financial investment is required.
First, health coverage needs to be extended to cover all expatriates so that the entire population is protected against health-related financial risks, ensuring a healthy population and workforce.Second, the health ministry should strengthen the governance of private health-care providers (e.g. by reviewing legislation to ensure health system rules apply to the private sector, and creating enforcement mechanisms to ensure the application of these rules), and ensure that they meet the same quality-of-care and operational standards as the public health-care sector.Third, progress towards services focused on primary health care needs to be invigorated by reviewing and updating the country model of care for more effective and efficient service delivery.Fourth, education to promote health (e.g.nutrition) and the prevention of noncommunicable diseases needs to be improved and better integrated into primary and community health care to reduce the load on secondary and more specialized health care.Fifth, financial investment into areas such as maternal and child health and vaccination should be increased to overcome gradual stagnation of outcomes in this area (e.g.there was only a minor improvement in infant mortality from 10.1 to 9.5 per 1000 live births during 2010-2020) [5][6][7] .Sixth, the governance and organization of health-care service providers should be reviewed and updated to improve the quality of care as well as increase the efficiency of resource use.Finally, because gaps in available data need to be addressed before a more extensive performance assessment can be conducted, finance to extend data collection and to ensure data quality and analytical capacity is essential.

Lessons learnt
We present a summary of the main lessons learnt during this rapid health system performance assessment process in Box 1.
Using such an analytical performance assessment framework enabled us to obtain a holistic view of health system inputs, processes, outputs and outcomes, essential for the identification of bottlenecks in the provision of population-wide health care.For example, the assessment highlighted that the health ministry has little information on the activities and quality of private healthcare service providers, demonstrating a lack of effective governance of this sector.Such knowledge deficiencies can mean that problems are not identified and corrective actions are not instigated.
Assessing the performance of a health system creates a high demand for data that few countries could fully meet using routine data collection methods.However, use of the WHO framework for assessing performance allows many common health indicators to provide information about multiple health outcomes.For example, during our rapid assessment we used data describing maternal mortality to gain information on health outcomes, quality of care and the performance of health system functions.
Finally, as well as identifying health-care issues that need to be incorporated within the next 5-year policy development cycle, our rapid assessment has assisted in the preparation for a more extensive health system performance assessment.With

Box 1. Summary of main lessons learnt
Use of a rapid health system performance assessment framework in Oman: • enabled us to obtain a holistic view of health system processes and outcomes, necessary for the identification of inefficiencies, restrictions, delays and gaps in data (e.g. a lack of information about private health-care providers); • allowed significant insights and benefits despite being conducted using modest resources and data already available; and • not only identified issues to be considered during the next 5-year policy development cycle in Oman, but also informed the preparation of a more extensive health system performance assessment.